Medicine vs. ER

nerdtonurse?, BSN, RN · Jul 22, 2008

What I would LOVE to see (telemetry, ICU step down nurse) is :

--Don't drop patients on us within 1 hour either side of shift change (7a or 7p).

--Don't drop patients on us when the computers are going thru their nightly reboot; if they start going south, I can't get into their records to see what they've already been given, if they're supposed to be NPO, etc.

--If we tell you we've got 4 nurses that already have 5-6 patients each, don't give us 6 patients at 2100 or the other big med passes (2100, 0400, 0600); how can anyone settle 2 patients at the same time, sign off orders, input drugs into the computer, get labs and tests ordered, and do the big 2100 med pass? Ask yourself, is this safe for the patients?

What I would rather is that we know straight up if we get a transfer, the transfers come at 2000, 2200, 2400, 0100, 0300, 0500, and then after shift change. The pharmacy could schedule med passes outside those hours, we could schedule things we could bump an hour (non essential dressing change, etc.) for those times. The ER could plan, we could plan, and nobody would feel like they were getting crapped on. If there's a bus crash on the interstate, that's different, but honestly, how many times is the situation actually that dire?

If we tell you we don't have a clean room, don't b***h us out because our NM says we are not to touch cleaning supplies, mops, etc., as an infection control issue (?!?). We can't get facilities to come, we can't get a patient. Sorry, that one's not on us, complain to our boss. Chances are, if we suddenly get an empty bed at 0315, it's not because the person went home (at least their earthly home), it's because we've got a bunch of upset family, a cadaver transporter coming, and are calling the organ bank. Would you want us to wheel your grandma up into the middle of that?

And lastly...if you get someone from a NH, for pete's sake, take their clothes off, including their diaper during the assessment. I am sick to death tired of "skin warm, dry and intact" only to discover a stage 4 sacral decube or heels that are rotting off.

TLCinCICU · Jul 22, 2008

What is the size of your hospital? Is it a teaching facility?

I'm an idealist among nurses. I'm actually one who wants to get the patient as soon as you have appropriate written orders that tell me what to do. Whether or not that makes it close to my shift change shouldn't even be a factor. Our medical director for ER/Triage has set a standard that all ER admissions are to be in a bed 45 minutes after the order to admit is written. Does it get met often? No. However, it does encourage us to shoot for the quickest we can accomplish.

Do you have a centralized department for bed admissions/transfers or does it just go through a house supervisor? Our Triage/Beds staff have the ability to page the housekeepers directly to change whether a bed is a "routine clean", "next clean", or "stat clean". And they are all nurses - not lay people. They contact doctors whenever the patient may be going to an inappropriate level of care.

kmoonshine, RN · Jul 22, 2008

What I would LOVE to see (telemetry, ICU step down nurse) is :
--Don't drop patients on us within 1 hour either side of shift change (7a or 7p).

Sometimes we can't help it. There's times that we're pulling patients into the halls because we are over-capacity; why is it fair to make the patient lay in the hall when they have a room ready for them upstairs?

--Don't drop patients on us when the computers are going thru their nightly reboot; if they start going south, I can't get into their records to see what they've already been given, if they're supposed to be NPO, etc.

I've seen some ED's use a nursing admit form that goes up to the floor with the patient. Things that are included on it are IV access, meds given, diagnosis, treatment, chief complaint, past medical hx, NPO status, and fall risk (I could go on and on). That way, if you didn't have computer access you would still have the necessary info to do your job.

--If we tell you we've got 4 nurses that already have 5-6 patients each, don't give us 6 patients at 2100 or the other big med passes (2100, 0400, 0600); how can anyone settle 2 patients at the same time, sign off orders, input drugs into the computer, get labs and tests ordered, and do the big 2100 med pass? Ask yourself, is this safe for the patients?

How can the ED nurses run from one room to the next, with their 5 patients all needing something, and suddenly there's 5 ambulances on their way, 5 min out. We can't tell the ambulances to drive around the block until we are ready to get report. However, I do empathize with you as I imagine all the admitting paperwork is time consuming. If I'm not slammed, I will hold on to my patient for a bit until the floor settles down.

What I would rather is that we know straight up if we get a transfer, the transfers come at 2000, 2200, 2400, 0100, 0300, 0500, and then after shift change. The pharmacy could schedule med passes outside those hours, we could schedule things we could bump an hour (non essential dressing change, etc.) for those times. The ER could plan, we could plan, and nobody would feel like they were getting crapped on. If there's a bus crash on the interstate, that's different, but honestly, how many times is the situation actually that dire?

Its actually quite frequent. Not necessarily a bus, but I've had 3 PNB's come in at the same time. I've also had 2 PNB codes running while a severe asthmatic needs to be intubated, only to find out that the patient in room 7 is a massive brain bleed and needs to be intubated also. Sometimes s**t hits the fan and we all need to work together. I like the idea of the scheduled transfer times and I think that concept should be a "courtesy", rather than a policy.

In response to the OP's question: rooms need to be cleaned promptly by housekeeping, regardless if a patient is waiting for that room or not. I think its so disgusting to walk past a patients room who had been discharged, only to see an unmade soiled bed, food on the floor, garbage overflowing, and commode sitting outside the door. There's been times that I've taken up tele patients throughout my shift, and those same "dirty" rooms remain untouched for hours.

You have to find out why the floor is resisting to move patients faster (is it lack of staff, an excess of paperwork, change of shift, etc). I've seen some places utilize a flow nurse (or even a few, depending on the size of the hospital). These nurses are a jack of all trades with experience in the both the ED and ICU, along with med-surg experience. They bounce between departments during their shift and help out where its needed; whether it be a difficult IV stick, multiple admits at one time, or several critical patients rolling into the ED all at once. The flow nurses have their own phone, and the unit's charge nurse calls the flow when/if they need their help. Once they are finished with the task they bounce onto the next one. Perhaps something like this would be helpful because it is a "catch-all" and a back-up in case things get out of control. When I was a student I had to call the hospital flow nurse because I had a difficult IV stick, and that sure worked better than poking the patient multiple times, and then asking a coworker to try, and then another...it saved a lot of pain and bruising, but it also saved time.

Th flaw is with the system, not the departments. You can't schedule when a patient will have a heart attack - and you can't choose who will get sick when. We're all short-staffed, underpaid, and overworked. On one end, staff are desperate to send an admit to the floor because there's too many things to do and the ambulances keep coming; on the other end, staff are resisting the admit because they too have too much to do with the time that they have. Meanwhile, supervisors are telling staff to speed up, pick up more patients, and focus on "time management". Lets be honest here: to meet a supervisor's time management goal, you'd have to provide unsafe, unsterile, and broken nursing care.

Have a round table discussion, and have 2 staff from each unit attend it and get to the bottom of the real problem. Also try to implement a reward system to reinforce the positives.

Roy Fokker, BSN, RN · Jul 22, 2008

* Where I work, we use what's called an "Admit nurse". They go around the ED and do the "nursing admission paperwork" (assess skin, get med list, go over detailed history etc. etc.). Every floor nurse I call report on breathe a HUGE sigh of relief when I tell 'em that the admit paper work has been done - and I can see why. The blessed thing is about 8-10 pages long! :eek: Unfortunately, we see so many patients that it's really the 'luck of the draw' as to whom the admit nurses get to see before they need to be moved to the floor (there is only so many of them and they can only do so much).

* No bed is assigned unless the room is ready and clean and a nurse has been assigned for the pt. This cuts down on the "bed is not ready" or "room is not clean" incidents.

* I agree with the general sentiment - don't send patients on either side of shift change. But believe me, I'm not doing it because I don't care... it's because I have no choice. Yes, a bus doesn't crash on the interstate everyday: but there are always severe abdominal pains, pregnant with severe bleeding, the "found unresponsives", the "knife wound to chest", the 3 month old with "respiratory distress", the threats with SI/HI so on and so forth.

Just because it ain't a trauma don't mean it's not an emergency. When I move a patient out, my bed doesn't stay empty - it's to make room for another patient.

I was a floor nurse and I know how hard it becomes when you get an admit at the end or start of your shift. But who would you rather take report from? Me - who has been with patient all day and ever since they came to the hospital... or from my replacement who has barely seen the patient and who can't give you a good idea of how much they've improved or not?

cheers,

Erin 321 · Jul 23, 2008

Thanks for the good ideas, everyone. I particularly liked the thoughts about courteous transfer times, a flow nurse (that's a really interesting idea) and the stuff that Roy mentioned. That's very helpful, thank you.

One post mentioned a reward system, which I'd considered in the past because of course there's no real incentive for the floors to take patients any faster than they have to (why take on extra work when you're already hopping and the breather might give you time to catch up?). I'd do the same thing, so the question then is, what would be the reward? How can we provide incentives that encourage everyone to promote flow in the department? We see it even in ER, I know people who try to hang on to their admitted patients because they already know them, they're settled and it's easier than taking on a new ER patient and starting from scratch. Has anyone worked in a facility that's employed some sort of incentive for this?

Also, one poster mentioned that she liked to receive patients within forty five minutes to an hour after the orders had been written. That's awesome but I just want to clarify that that's not quite the issue in our hospital. We consider being at 53% capacity with admissions a really good day, with waits in ER from less than 1 day to up to a week (!), averaging 2-3 days wait for a medicine bed. If it was just an hour or two, no big deal, but as you can imagine, after several days, both the patient and the nurse get a bit antsy when they find out there's finally a bed available!

Thanks again for the tips.

kmoonshine, RN · Jul 23, 2008

I guess by "rewards", I was refering more to appreciation and less to incentive.

One place where I worked filled a bowl up with candy (it was actually filled with lots of good treats). It was passed between different departments when a department did a good job. It was just a way to say "thanks, we appreciate what your unit did for us". Today all we seem to focus on are the things that need improvement - but we need to acknowledge the things that we do well also.

Sounds kinda cheesy, I know. But wouldn't you rather be talked to by management because of something great that you did? Sometimes its the little things that make people happy...

nerdtonurse?, BSN, RN · Jul 23, 2008

Note to self: do not post after a bad night at work. Sorry guys.

We'd had a bad night with some new folks in the ER when I did my first post. We're not a very big hospital, and when folks do PRN for us from the big hospital 50 miles away, they don't understand that we've only got 36 tele beds, and that's all; they're used to having a hundred, and much lower staffing ratios than we have. Honestly, we're not hiding a whole additional floor full of staff and beds from you....

On a constructive note, I think teambuilding between the units, including monthly floats would be a good idea if you could swing it at your facility (sounds bigger than ours). Anything that erases the "us vs. them" thing would be good.

Also, if there are specific things to your floor (like only having 36 tele beds, or having a couple of rooms out of commission due to problems with the heater or AC) let the ER charge know that kind of thing. It causes needless friction when the ER staff see empty rooms on our floor, but they don't realize that the facility hasn't fixed the air yet, or we're out of tele boxes.

Likewise, if the ER knows they're getting slammed, give the floors a heads up -- tell us you're not looking for a bed assignment yet, but you know we're going to get 5 admits. We had that last night, and because we had a different ER crew, we got a heads up, so we had time to take folks out of singles and put them into doubles so we could put the MRSA folks and our AMS/violent outburst person into singles, did some meds early/tube feedings a little early, pushed back some dressing changes, etc., so that we could take the slam without killing ourselves (or a patient!), and still beat the computer system going down for nightly maintenance.

Having a questionaire where you ask each group the simple question: "what would you like ER/medsurg/ICU do to make your work easier?" might get some "drop dead" answers, but you'd probably get some good ideas from the staff. Your folks know the issues at your facility, and they may have great untapped ideas.

Rnandsoccermom · Jul 23, 2008

one place i worked at, the patients always came up with a peripheral site started and admitting orders from the attending. i never really minded taking admits there. all i had to do was my assessment and initiation of the orders-i really appreciated that. then the attending didn't have to be bothered again and i didn't have to start at square one with a patient who had already been waiting for 8 hrs in the er.

Roy Fokker, BSN, RN · Jul 23, 2008

I like the reward/incentive idea.

Anything that erases the "us vs. them" thing would be good.

I agree. I really don't like that attitude from my peers - be they floor nurse or ER nurse or ICU nurse.

Likewise, if the ER knows they're getting slammed, give the floors a heads up -- tell us you're not looking for a bed assignment yet, but you know we're going to get 5 admits.

Good point - but the trouble is, you never know who is gonna get admitted... much less "where" are they going (med-surg, tele, ICU?)

There have been plenty of times when ER doc comes and tells me "Pt. XYZ is going to inpatient Med surg. Dr. So So is gonna write orders." An hour passes, Dr. So So has written orders - but wants patient to go to Tele floor and not Med-Surg. It's annoying to every one when it happens...

There have also been walkie-talkies being "admitted to s/u for observation" when their CT comes back with a massive bleed in their head who now need to be airlifted pronto to big hospital 50 miles out... :bugeyes:

Your folks know the issues at your facility, and they may have great untapped ideas.

I think the next time I take patients up, I'll stop for a second and ask around

One place I worked at, the patients always came up with a peripheral site started and admitting orders from the attending.

I usually try to place peripherals - unless otherwise needed. And any orders written, I usually do the stuff I can now (like meds/abx. Or start their CT prep. if ordered etc.)

cheers,

kmoonshine, RN · Jul 24, 2008

I don't think I've ever sent an admit up without a PIV! Although, placing an IV is my favorite thing to do - the harder the stick, the better! :loveya:

And for you ICU nurses: I'll send my patients with at least 2 PIV's, 18g or higher.

I try to do as much for you as I can...and then some.